Aubagio Start Form | Download & Complete Online

Aubagio Start Form

Auabgio (teriflunomide) is a prescription medication for eligible patients suffering from multiple sclerosis (MS). Accurate completion of the Aubagio Start Form is crucial for patients to access One-to-one support services for Aubagio. It ensures a copay assistance program and One-to-One Nurse support to eligible patients.

You must click the download button below to save this fillable blank form on your device. Moreover, you will know its purpose, how to complete this form, and essential details to avoid delays.

Aubagio Start Form
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Purpose of Aubagio Enrollment Form Fillable

It is a standard document used to participate in the patient assistance program to mitigate financial burdens. However, it has the following main objectives.

Patient Enrollment

The completion of this form ensures registration in the Aubagio Support Program to get financial benefits for the medication.

Insurance Verification

It assesses the insurance coverage to meet the requirements for participation in the support program through private or public insurance plans.

Financial Assistance

It provides an opportunity for eligible patients for copay assistance to get free medication or at a lower price.

Pharmacy Coordination

It streamlines the timely medication delivery process to the patients.

How To Download a Fillable Aubagio Patient Start Form PDF

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  • Step 1: Type www.formsdude.com in any web browser to visit the homepage.
  • Step 2: Type the form’s name (Aubagio Start Form) in the search bar.
  • Step 3: Search for the fillable blank PDF form in the result.
  • Step 4: Click the download button to save it instantly.
  • Step 5: Open and fill out the form using the PDF editor.
  • Step 6: Fortunately, you can fill out this form here and press the print button for a printout immediately.
  • Step 7: Re-check the filled form and submit it.

Step-by-Step Instructions for Filling Out the Blank Aubagio Patient Assistance Form

Follow the steps below to complete this form accurately.

1- One to One Services Authorization

The patient or representative will sign here with the date for service authorization and its terms and conditions.

2- Authorization to Share Health Information

The patient will also sign here with the date to give authorisation for sharing the health information with Sanofi Genzyme and its agents. If any representative is completing this form on behalf of the patient, write his/her name and relationship below.

3- Patient Information

Write the patient’s gender, date of birth, name, address, phone number, mobile number, best time for call, email address, and preferred language.

4- Prescriber Information

Write the prescriber’s name, state license number, NPI number, Tax ID number, primary contact name and number, and email address. Also, write the facility name, address, contact number, and fax number.

5- Medical Coverage

Write the primary and secondary insurance name, their policy number, group number, policyholder’s name, date of birth, and phone number.

6- Prior Treatment

After diagnosis, the prescriber will tick the required treatment and its duration.

7- Commercial Information – Aubagio Tablets

The prescriber will tick the medication strength, shipment quantity, and refill quantity. Also, write special instructions if required.

8- One Start Prescription for Eligible Patients

During the benefits treatment process, the prescriber is authorised to tick the “Yes” or “No” box for One Start at no cost to patients.

9- Prescriber Authorization

The prescriber will write his/her name and sign the form with the date to start the process.

Essential Information While Filling Out the Aubagio Start Form

The following details are essential to consider while filling out this form to avoid complications for assistance programs.

Provide Accurate Information

You must ensure you provide accurate information about the patient and their medical history to fulfil the requirements.

Insurance Coverage

If the insurance coverage is denied, consult the healthcare provider or your Nurse to appeal for denials and get education about the medication.

Attach Supporting Documents

You must gather and attach all required documents to this form to avoid delays.

Record Keeping

To maintain your records, you must keep a copy of this form for future reference.

FAQs

What is an Aubagio Start Form?

It is a crucial document that contains the patient’s personal and insurance details for the prescriber’s authorization to get medication. It streamlines the medication process and provides financial assistance to patients who need to get free medication or at a lower price.

What is Aubagio?

It is a medication treatment for eligible patients suffering from severe multiple sclerosis (MS). The eligible patients get medication doses as per schedule to get relief.

What Documents are Required to Participate in One-to-One Nurse Support?

You need to gather the patient’s identity proof, front and back copies of insurance cards, and past medical history.

How Can I Submit the Aubagio Enrollment Form?

After accurate completion, Aubagio one to one start form can be submitted via fax, mail, email, or online process.

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